Abstract He mangio mas are co mmon benign lesions of the head and neck which predominantly orig inate fro m lips, tongue and buccal mucos

Borlingegowda Viswanatha

C Ravishankar

N Dhanapala

Ramya B

Supriya Bhat

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Research in Otolaryngology 2013, 2(1): 12-14 
DOI: 10.5923/j.otolaryn.20130201.03 
 
A Rare Case of Sinonasal Cavernous Hemangioma 
N. Dhanapala*, C. Ravishankar, Ramya B., Supriya Bhat, Borlingegowda Viswanatha 
Department of ENT, Bangalore Medical College and Research Institute, Bangalore, India 
 
Abstract  Hemangiomas are common benign lesions of the head and neck which predominantly orig inate from lips, 
tongue and buccal mucosa[1]. They occur infrequently in the sinonasal cavity[2]. Maxillary sinus hemangiomas are 
extremely rare[3]. They can produce destruction of the adjacent bones, making it difficu lt to differentiate it from the more 
common malignant epithelial tumors on the basis of imaging[2]. We report a case of maxillary sinus cavernous hemangioma 
in a 30 yr old male treated with endoscopic sinus surgery. 
Keywords  Sinonasal, Cavernous, Hemangioma 
 
1. Introduction 
Hemangiomas histologically are d ivided into two types, 
capillary and cavernous, depending on the dominant vessel 
size at microscopy[4]. The sinonasal cavity is an uncommon 
site of hemangiomas of the head and neck[2]. Most nasal 
hemangiomas arise from the nasal septum or vestibule and 
are of capillary type. Only a few arise from lateral wall of the 
nose and these are usually cavernous[5]. Being rare, they can 
cause diagnostic and therapeutic problems[6]. 
Benign cavernous hemangiomas like inverted papillomas / 
sinonasal polyps can cause bone erosion, the appearance of 
which on CT scan can mislead the radiologist to the false 
diagnosis of a malignant tumor. At angiography, foci of 
pooling of contrast material within the lesion confirm the 
diagnosis of hemangioma. Complete excision of tumor is the 
treatment of choice. 
2. Case Report 
A 30 yr old male presented to us with right sided nasal 
obstruction and intermittent epistaxis of 4 months duration. 
On  examinat ion , the right nasal cav ity  was completely 
obstructed by a friab le, reddish-brown mass arising from the 
lateral wall which  b led  on  p rob ing . CT s cans  after 
Intravenous admin istration of contrast material showed a 
large heterogenous minimally enhancing soft tissue mass in 
right maxillary sinus and nasal cavity with the anterior and 
posterior walls o f maxillary s inus were part ially  eroded. 
Excis ion  b iopsy  o f the nasal mass  was  done and  the 
h istopatho logy  report  s howed  featu res  o f cavernous 
hemangioma. Subsequent ly , endoscop ic excision  o f the  
 
* Corresponding author: 
ndhanpal@gmail.com (N. Dhanapala) 
Published online at http://journal.sapub.org/otolaryn 
Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved 
maxillary  mass was done along with medial maxillectomy. 
Intra-operatively the anterior wall was found to be papery 
thin and the posterior wall was partially eroded. The intra 
and post-operative periods were uneventful with no 
significant hemorrhage encountered. Histopathology of the 
specimen confirmed  the diagnosis of cavernous hemangioma 
with no features of malignancy. The patient is asymptomat ic 
with no recurrence 15 months after surgery. 
3. Discussion 
Hemangiomas, histologically are div ided into two  types, 
capillary and cavernous, depending on the dominant vessel 
size at microscopy[4]. Sinonasal hemangiomas are rare and 
when they occur they usually arise from nasal septum and 
vestibule. They are predominantly of cavernous type[2]. 
Maxillary sinus hemangiomas are extremely rare[3]. A 
recent review reported only 17 maxillary  sinus hemangioma 
cases in the literature[7]. Maxillary sinus hemangiomas grow 
slowly and cause local destruction due to pressure effect[8]. 
Cavernous hemangiomas have a microscopic appearance of 
large b lood filled canals lined with a single layer of 
endothelial cells and separated by scanty connective tissue 
stroma. Histologically, they are sharply defined but 
encapsulated lesions[6]. CT scan may show a) non 
homogenous mass due to areas of hemorrhage and necrosis, 
b) changes in adjacent bone with sinus expansion, c) bone 
destruction misinterpreted as sign of malignancy and / or d) 
phleboliths due to dystrophic calcification following 
intravascular thrombosis. But CT /  MRI do not provide 
pathognomonic data for haemangiomas[8]. CT and MRI are 
especially of use to reveal the boundaries and the soft tissue 
extension of the lesion. Angiography is always warranted if 
there is any suspicion about the nature of these vascular 
tumors, as it enables us to decide if there is any need for 
transarterial embolizat ion, in  order to prevent hemorrhage 
during surgical intervention[2]. 
 Research in Otolaryngology 2013, 2(1): 12-14 13 
 
 
Differential diagnosis should include neuroma, inverted 
papilloma, mucocele and other benign or malignant vascular 
tumors[8]. Complete excision of the tumor is the treatment of 
choice and no recurrence has been reported following 
paranasal hemangioma surgery[6]. Intraoperative 
hemorrhage related to hemangiomas is variable and it 
presents with min imal or massive bleeding[7]. The fear of 
sudden loss of large quantities of blood is more with 
cavernous hemangiomas than with capillary type[9]. In our 
case, the short history and partial erosion of anterior and 
posterior maxillary walls arouse a high degree of suspicion 
of malignancy. The opacification of ethmoidal cells which 
were interpreted as inflammatory changes due to obstruction 
of middle meatus were confirmed during surgery. 
  
Figure 1.  Coronal CT image of Paranasal sinuses showing heterogenous 
mass occupying right maxillary sinus and right nasal cavity 
 
Figure 2.  Coronal CT image of Paranasal sinuses showing heterogenous 
mass occupying right maxillary sinus and right nasal cavity 
 
Figure 3.  Axial CT image of paranasal sinuses showing heterogenous 
mass occupying the right maxillary sinus along with partial erosion of 
anterior wall of the maxillary sinus 
  
Figure 4.  Histology slides showing large (cavernous) spaces, lined by 
tumor endothelial cells (which appear very similar to normal cells). These 
interconnected spaces are filled with blood and separated by a fibrous tissue 
 
Figure 5.  Histology slides showing large (cavernous) spaces, lined by 
tumor endothelial cells (which appear very similar to normal cells). These 
interconnected spaces are filled with blood and separated by a fibrous tissue 
4. Conclusions 
Sinonasal tumors with bone erosion should not be 
presumed to be malignant always. Benign cavernous 
hemangiomas of sinonasal cavity, though rare, can cause 
substantial bone erosion and should be considered in the 
differential diagnosis of sinonasal tumors. 
 
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A Rare Case of Sinonasal Cavernous Hemangioma

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A Rare Case of Sinonasal Cavernous Hemangioma

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